Multiple problems may lead to incontinence in these patients: urethral sphincter weakness, UTI, urinary urgency or involuntary bladder contractions, bladder atony and/or overflow incontinence associated with obstruction. Hopefully the primary causes associated with the abnormal voiding function have been defined, but often “shotgun” methods (anti-muscarinic drugs or catheterization) begin without full evaluation. Foremost amongst these is use of bladder catheterization for the control of incontinence [8]. Newman et al. point out that reduction in catheter use to treat incontinence is one of the mandates of the Centers for Medicare and Medicaid Services (CMS) issued in 2005. This, of course, helps in decreasing the related incidences of UTI, urethral erosion, urethritis and epididymitis and especially in females, catheter expulsion. If the indwelling urethral catheter does become the method chosen, the next questions are: [1] how often should it be changed, especially if one is to reduce the risk of symptomatic urinary infection and [2] how should the catheter be cared for? These dilemmas present some of the strongest reasons for urologists to be well acquainted with nursing home care.

Priefer et al. [9] performed an interesting study of patients in a VA Nursing home. Catheters were changed in two random groups: group 1 only for acute infection or catheter obstruction (7 men), and group 2 on a regular monthly schedule as well as for infection or obstruction (10 men). Six of the former group (86%) developed symptomatic UTI while only three of ten in group two did so (30%). Obviously, this was a limited study, but it seems to corroborate the usual advice to change indwelling urethral catheters on a monthly basis.

Nursing homes usually have available noninvasive devices for measurement of bladder residual urine volume. These assist the urologist in decisions about degree of obstruction or inadequate bladder emptying. If increased residual exists, then conservative treatment methods may lead to a satisfactory resolution, but again, an indwelling catheter is frequently attempted as the first intervention, rather than preferred alternate techniques such as sterile or clean-intermittent-catheterization (CIC) [10]. If the patient can perform CIC, then that is better for them. If it must be done by nursing personnel, the time requirements may seem excessive, but the proven decrease in symptomatic UTI for intermittent over indwelling catheterization pleads for the use of CIC [11]. Of course, if increased residual is related to outlet obstruction, some procedural intervention to relieve obstruction may be necessary. In the absence of obstruction, other simple procedures such as timed voiding, double voiding or expedited access to a commode may be the only interventions needed [3, 12].

When problems such as recurrent urethral erosion appear in a patient, the question of inserting a suprapubic tube arises. Our judgment often results from the success or failure of previous attempts to correct the voiding dysfunction: relief of outlet obstruction by surgical intervention in the up and about patient, intermittent catheterization in any patient where the obstruction or bladder atony cannot be overcome, use of condom catheters where incontinence exists without obstruction. When all these interventions that may be tried have failed, then perhaps a test of suprapubic catheterization may be performed with a percutaneous insertion under ultrasound guidance [13]. If this provides adequate improvement, a more permanent retention catheter can be placed by gradual size increases.

One of the complications that the suprapubic catheter helps to avoid is the meatal or urethral erosion sometimes associated with indwelling catheterization (Fig. 8.2). But another way to avoid the complication is to conduct educational programs for the staff charged with catheter management [14]. Proper draping of the drainage tube to avoid urethral tension, and attention to re-draping when the patient is repositioned resulted in a decreased number of these events in our experience.

Another of the significant problems encountered in the nursing home patient is the presence of bacteria in the urine: asymptomatic or symptomatic? We know that this is common in conjunction with long-term indwelling catheter, but it also occurs in the catheter free patient. What is the significance of these bacteria? Juthani-Mehta [15] published an extensive review on this subject and presented precise requirements for diagnosis of asymptomatic bacteriuria versus UTI. One question that always arises is the validity of using a dipstick to detect infection. Perhaps the most important component here is that a negative dipstick strongly mitigates against bacteriuria and thus against UTI. However, any dipstick positivity must be followed by a properly collected urine specimen for culture.

Notably, the incidence of asymptomatic bacteriuria increases with increasing age and thus (from our Fig. 8.1) in community or nursing home populations, being barely 1–2% until age 65, but over 6% thereafter in community dwelling elderly. For those patients in LTC institutions, the prevalence is greater than 15%. Sometimes this finding of bacteriuria is associated with symptoms of true infection: fever, painful urination, and so forth. But these symptoms may not clearly diagnose true UTI: “To date no constellation of symptoms is identified in older adults who have bacteriuria that can distinguish symptomatic from asymptomatic patients reliably in all situations” [15]. However, in the presence of symptomatic bacteriuria, presence of at least three of four criteria may be useful in deciding to treat (Table 8.1).

Another vexing problem seen in the LTC patient is hematuria. This may be found microscopically on routine urinalysis (and remember that to be considered significant by American Urological Assn criteria must be greater that 2 RBC/HPF in at least two microscopic examinations of adequately collected urinary specimens) [16] or perhaps grossly present and noted by the patient or nursing personnel. Dipstick positivity for hematuria is not adequate for defining true hematuria. In any case, this drives the urologist toward standard evaluation including collection of specimen for cytology, anatomic imaging, and cystoscopic examination. However, questions always arise about the necessity of such procedures in the bed-ridden demented patient or one with multiple co-morbidities for whom no significant intervention would be considered. In such situations, one must consult with responsible family or guardian or other individual with health care power of attorney.